Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth
MassHealth
Personal Care Agency Bulletin 6
November 2011
TO: Personal Care Agency and Transitional Living Providers Participating in MassHealth
FROM: Julian J. Harris, M.D., Medicaid Director
RE: MassHealth Community Services Critical Incident Report Form
Background Personal care agency (PCA) and transitional living (TL) providers currently report
critical incidents to MassHealth. This bulletin clarifies the types of incidents
(hereafter referred to as critical incidents or incidents) that TL providers must report
to MassHealth, describes the process for reporting critical incidents, and
introduces the MassHealth Community Services Critical Incident Report Form as
the standard critical incident report form to be used by TL providers and other
community services providers.
The new MassHealth Community Services Critical Incident Report Form was
developed solely for the purpose of reporting critical incidents to MassHealth.
Submission of the form does not alter any provider liability for the incident, nor
does it supersede or negate any independent responsibility the provider may have
to report the incident to other authorities.
New Form and This bulletin provides you with a copy of the form. The form also contains
Instructions instructions and a contact list. A sample of the form is attached to this
bulletin.
Effective immediately, TL providers must begin using the attached MassHealth
Community Services Critical Incident Report Form, and follow the attached
reporting protocol described in the MassHealth Community Services Critical
Incident Reporting Instructions.
Supplies The MassHealth Community Services Critical Incident Report Form is also
available on the MassHealth Web site. Go to www.mass.gov/masshealth. Click on
Provider Forms. The form is listed under the heading Multiple Provider Types. You
may photocopy the form as needed.
Questions If you have any questions about the information in this bulletin, please contact the
appropriate MassHealth program manager (Refer to the last page of the
MassHealth Community Services Critical Incident Report Form for MassHealth
contact information.)
MassHealth
Personal Care Agency Bulletin 6
November 2011
Attachment
MassHealth Community Services Critical Incident Report Form
This form is to be used by MassHealth community services providers (See Section 2 below) to
report to MassHealth the occurrence of a reportable critical incident (hereafter the “incident”)
involving MassHealth members. The MassHealth Community Services Critical Incident Report Form is
for the sole purpose of reporting the occurrence of an incident to MassHealth. Submission of the
form does not alter any provider liability for the incident, nor does it supersede or negate any
independent responsibility a provider may have to report the incident to other authorities.
Instructions
Verbal Communication and Immediate Notification (See Critical Incident Reporting Instructions)
Upon learning of the occurrence of a reportable critical incident, the provider must immediately
contact the appropriate MassHealth program manager by phone to report the incident. If a
reportable critical incident occurs on a weekend day or holiday when MassHealth offices are
closed, the provider must report the incident on the next business day. By the close of business
on the date the provider first learned of the incident, the provider must submit a preliminary
report to the MassHealth program manager.
(See Program Manager Contact Information).
Report Submission
Within three business days of learning of the incident, the provider must complete the MassHealth
Community Services Critical Incident Report Form and submit it to the appropriate MassHealth
program manager. The provider submitting this form must also contact and update the MassHealth
program manager if a significant change occurs in an affected member’s condition that resulted
from the incident.
Section 1. General Information (Complete one report form for each reportable critical incident.
If multiple members are affected, list all affected members in Section 5.)
Member name:
Date, time, and location of incident:
Address and phone number of member(s):
Name, address, and phone number of provider:
Section 2. Type of MassHealth Community Services Provider
___Adult Day Health
___Group Adult Foster Care
___Transitional Living
___Day Habilitation
___Adult Foster Care
Section 3. Witness of Incident
Name and contact information of person reporting or witnessing incident:
Name and contact information of person filing report (if different from witness):
Names and contact information of all individuals involved in the incident:
CIRF (11/11)
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Section 4. General Nature of Incident (Check all that apply. Attach additional pages if needed.)
___Death of a member from non-natural causes, including
suicide, homicide, or other unexpected cause for death
___Exposure to hazardous material (including blood
borne pathogens)
___Medication errors (requiring medical intervention)
___Person missing from scheduled care
___Mistreatment or allegations of mistreatment including
abuse, neglect, emotional harm, or sexual or financial exploitation
___member to member
___Other (specify):
___Natural disaster, such as fire or incidents causing
displacement (explain):
___Serious communicable disease required to be reported to
health authorities pursuant to state and/or local ordinances
___member
___staff
___Other (specify):
___Serious physical injury (requiring medical treatment beyond
basic first aid), including self-inflicted injury or when cause or origin of injury is unknown.
___Significant property damage to provider’s premises
___Suspected or alleged criminal activity
___Media involvement (specify):
___Other unusual or serious incident (specify):
Section 5. Describe Incident and Cause (Include location and events preceding incident.
Attach additional pages if necessary. For multiple members, please list all affected members
in this section.)
Section 6. Interventions and Outcomes (Attach additional pages if needed.)
Action taken by provider and outcome:
Medical intervention taken if needed (Include name of physician or other health care
professional, contact information, and action ordered.):
Police or any other investigator authorities (Describe involvement, provide contact information,
and attach any reports from listed authorities.):
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Section 7. Member’s Current Status (Include health and other status.)
___Emergent primary care physician visit
___Emergency room visit
___Hospitalization
___Nonroutine PCP visit
___Stable
___Unstable
___Further followup required after incident (explain):
Section 8. Other Parties or Agencies Contacted (e.g., family, HCP, hospitals, etc.)
___Agencies (e.g., VNA, HHA, case manager, residential
program, etc.)
___Division of Children and Families (under age 18)
___Disabled Persons Protection Commission (DPPC) (ages 19-59)
___Elder Affairs Protective Service (ages 60+)
___Family/caregiver
___Guardian
___Hospital
___Police
___Primary care physician or other health care practitioner
___Other (specify):
Section 9. Describe Corrective Action Taken to Prevent Future Incidents
Section 10. Provider Signatures
I certify that the information on this form and any attached statement that I have provided has
been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge.
Printed Name:
Signature:
Title:
Date:
Signature of program director (or other person responsible for day-to-day management of provider):
Printed Name:
Signature:
Title:
Date:
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MassHealth Community Services Critical Incident Reporting Instructions
MassHealth community services providers are required to have quality assurance policies and
procedures to prevent and minimize the potential for incidents and/or accidents, as well as
policies and procedures to minimize the impact to MassHealth members from any incidents or
accidents that do occur. If a critical reportable incident (hereafter the “incident”), as defined
below, occurs while the provider is providing care, the provider is responsible for investigating
the incident and must complete and submit a MassHealth Community Services Critical Incident Report
Form to MassHealth.
The MassHealth Community Services Critical Incident Report Form is for the sole purpose of
reporting the incident to MassHealth. Submission of the form does not alter any provider
liability for the incident, nor does it supersede or negate any independent responsibility a
provider may have to report the incident to other authorities.
1. Definitions
Caregiver—any person or organization who is responsible for providing direct care to a MassHealth
member, where the care is paid for by the MassHealth program.
MassHealth Community Services Provider—for the purpose of the Community Services Critical
Incident Report Form, a MassHealth community services provider includes the following provider
types:
• Adult Day Health;
• Adult Foster Care;
• Group Adult Foster Care;
• Day Habilitation; and
• Transitional Living.
Reportable Critical Incident—any sudden or progressive development (event) that requires
immediate attention and decisive action to prevent or minimize any negative impact on the
health and welfare of one or more MassHealth members. Critical incidents may include but are not
limited to:
a. serious physical injury, including a self-inflicted injury and injuries where the cause
or origin is unknown and where the member requires medical treatment beyond basic first
aid;
b. any serious communicable disease that is required to be reported to health authorities
pursuant to state and/or local ordinances;
c. natural disaster such as fire, serious flooding, or incidents causing displacement;
d. exposure to hazardous material (including blood-borne pathogens);
e. medication error (requiring medical intervention);
f. mistreatment or allegation of mistreatment of a member including abuse, neglect,
emotional harm, sexual or financial exploitation, or any other mistreatment, whether
perpetrated by staff or member to member;
g. person missing from scheduled care;
h. significant property damage to the provider’s premises;
i. suspected or alleged criminal activity occurring while the provider is providing care; and
j. death of a member from non-natural cause, including suicide, homicide, or any other
unexpected cause for death.
2. Reporting
Preliminary Report. All reportable critical incidents must initially be reported by phone, fax,
or e-mail to the appropriate MassHealth program manager (See Program Manager Contact Information).
This preliminary reporting must be communicated to the MassHealth program manager by the close of
business on the day of the incident and must include, at minimum:
a. the name of the person(s) involved;
b. the date, time, and location of the incident;
c. events preceding the incident;
d. a description of the incident;
e. immediate actions taken and outcomes;
f. any witness(es) to the incident;
g. the extent of injury to the affected member(s), including any medical or other health
care professional’s treatments or recommendations;
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h. other parties involved (police, fire department, etc.) and their actions and the results,
including any recommendations;
i. the current status of the affected member(s);
j. corrective action taken to prevent future incidents, including implementation time lines;
and
m. media involvement.
MassHealth Community Services Critical Incident Report Form. The caregiver (and/or the provider’s
program manager/supervisor’s designee) who observes or discovers a reportable critical incident
must record the incident as soon as possible on the MassHealth Community Services Critical
Incident Report Form, and forward the form to the provider’s program director or designee
upon its completion.
The program director or designee must conduct any necessary immediate followup and submit the
completed and signed MassHealth Community Services Critical Incident Report Form to MassHealth
within three business days of the date the program director or designee learns of the reportable
critical incident. If, at any time, there is a significant change in an affected member’s
condition relating to the reportable critical incident, the provider’s program director or
designee must immediately report this to the appropriate MassHealth program manager, and provide
a written report by the end of business on the date the significant change in condition occurred.
3. Recordkeeping
MassHealth providers must comply with the applicable MassHealth provider regulations and policies
for the maintenance of records. This includes maintaining documentation of reportable critical
incidents, along with any ongoing notes, observations, and follow-up action in any affected
member’s record, or in a separate accessible file.
4. Injury Resulting From Suspected Abuse or Neglect by the Caregiver
If a MassHealth provider has reasonable cause to believe that serious physical injury (including
fatal injury) or emotional injury of any individual served by the provider resulted from actions
of a caregiver, whether by act or omission, the provider must
a. immediately call the Disabled Persons Protection Commission (DPPC) and file a complaint
under M.G.L. c. 19C, if the victim of the alleged abuse or neglect is disabled and is 18
years or age or older, but under 60 years of age;
b. immediately call the Department of Children and Families (DCF) and file a report under
M.G.L. c.119, § 51A, if the victim of the alleged abuse or neglect is under 18 years of
age;
c. immediately call the Executive Office of Elder Affairs (EOEA) and file a report under
M.G.L. c. 19A, § 15, if the victim of the alleged abuse or neglect is 60 years of age or older;
d. immediately call the Department of Public Health and file a report under M.G.L. c. 111,
§ 72G, if the victim of the alleged abuse or neglect resides in a nursing facility or
similar establishment required to be licensed or certified by the Department of Public
Health; and
e. immediately contact the local police department when the provider has reasonable cause to
believe that a felony has been committed in connection with an incident.
Reports filed with any other agency are investigated in accordance with the regulations and
procedures of that agency. The filing of a report with any other investigative agency does not
negate or satisfy the community services provider’s requirement to submit a MassHealth Community
Services Critical Incident Report Form to MassHealth.
5. Written Updates
Once the MassHealth Community Services Critical Incident Report Form has been submitted to the
appropriate MassHealth program manager, additional updates may be necessary to keep MassHealth
informed of the matter. Examples of incidents requiring ongoing updates include, but are not
limited to
• incidents affecting multiple members;
• incidents that cause serious injury to a member;
• natural disasters, such as fire or flood; or
• incidents causing displacement.
If additional updates are requested by MassHealth, the providers must respond to MassHealth’s
request for additional information within 30 calendar days.
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MassHealth Community Services Critical Incident Reporting
Program Manager Contact Information
As stated in the MassHealth Community Services Critical Incident Reporting instructions,
MassHealth providers must submit completed MassHealth Community Services Critical Incident
Report forms to the appropriate MassHealth program manager or contact person listed below, by
mail, fax, or e-mail.
Please Note: Providers are reminded that they are covered entities under HIPAA and that, pursuant
to HIPAA requirements, protected health information (PHI) must be sent in a secure fashion.
Providers wishing to submit PHI by e-mail must make sure that the e-mail transmission is secure.
Completed MassHealth Community Services Critical Incident Report forms should be mailed or faxed
to the following address and to the attention of the appropriate manager or contact person listed
below.
MassHealth Office of Long Term Services and Supports
One Ashburton Place, 5th Floor
Boston, MA 02108
Fax Number: 617-727-9368
Program Managers and Contact Information
Adult Day Health Services and
Adult Foster Care Services
Beth Shelton, Program Manager
Phone: 617-222-7485
E-mail: Beth.Shelton@state.ma.us
Day Habilitation Services
Jennifer Reid, Manager
Phone: 617-222-7565
E-mail: Jennifer.L.Reid@state.ma.us
Group Adult Foster Care Services
Pam Gardner, Program Manager
Phone: 617-222-7486
E-mail: Pamela.Gardner@state.ma.us
Transitional Living
Sandra Brown, RN, Contact Person
Phone: 617-222-7410
E-mail: Sandra.Brown@state.ma.us